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What does complete revascularization mean in 2021? - Definitions, implications, and biases. Curr Opin Cardiol 2021; 36:748-754. [PMID: 34483299 DOI: 10.1097/hco.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Coronary revascularization is known to be an excellent treatment for coronary artery disease. However, whether incomplete myocardial revascularization compromises long-term outcomes, as compared to complete revascularization (CR), remains contentious. Herein, we review the concept of and evidence on CR/incomplete revascularization (ICR) and discuss future perspectives. RECENT FINDINGS When possible, achieving CR in coronary artery bypass grafting is desirable; nonetheless, ICR is also a reasonable option to balance the therapeutic benefits against the risks. SUMMARY Although angiography-based assessment currently remains the standard of care, fractional flow reserve guidance may reduce the number of lesions requiring revascularization, which may be helpful for an appropriate surgical revascularization strategy. In particular, utilizing this approach may refine hybrid revascularization procedures, especially among high-risk patients.
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Yuksel A, Yolgosteren A, Kan II, Cayir MC, Velioglu Y, Yalcin M, Tok M, Bicer M, Signak IS. A comparison of early clinical outcomes of off-pump and on-pump coronary artery bypass grafting surgery in elderly patients. Acta Chir Belg 2018; 118:99-104. [PMID: 28946812 DOI: 10.1080/00015458.2017.1383087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The reply of question of "which coronary artery bypass grafting (CABG) technique is superior in elderly patients, off-pump or on-pump CABG surgery?" is controversial. We aimed to compare the early clinical outcomes in elderly patients undergoing off-pump and on-pump CABG. METHODS From January 2009 to January 2015, 344 elderly patients (aged 70 or older) underwent off-pump (n = 137) or on-pump (n = 207) CABG. Patients' medical records were retrospectively reviewed, and their baseline preoperative characteristics, operative data and postoperative outcomes were analyzed, thereby a comparison of early outcomes between off-pump and on-pump patients was performed. RESULTS Mean age of patients was 74.4 ± 3.8 years. Both groups were statistically similar in terms of baseline preoperative characteristics. Number of distal bypass was significantly lower in off-pump group than in on-pump group. Postoperative length of intensive care unit and hospital stay were similar between two groups. Amounts of transfused blood products were significantly lower in off-pump CABG group. There were no significant differences in terms of postoperative complications and mortality between two groups. CONCLUSIONS Our results did not reveal a significant benefit of either surgical technique with respect to early-term clinical outcomes in elderly CABG patients. Further investigations are needed to determine whether off-pump CABG is superior than on-pump CABG in elderly patients.
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Affiliation(s)
- Ahmet Yuksel
- Department of Cardiovascular Surgery, Bursa State Hospital, Bursa, Turkey
| | - Atif Yolgosteren
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Iris Irem Kan
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | | | - Yusuf Velioglu
- Department of Cardiovascular Surgery, Abant Izzet Baysal University Faculty of Medicine, Bolu, Turkey
| | - Mustafa Yalcin
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Mustafa Tok
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Murat Bicer
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Isik Senkaya Signak
- Department of Cardiovascular Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
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Dhurandhar V, Saxena A, Parikh R, Vallely MP, Wilson MK, Butcher JK, Black DA, Tran L, Reid CM, Bannon PG. Comparison of the Safety and Efficacy of On-Pump (ONCAB) versus Off-Pump (OPCAB) Coronary Artery Bypass Graft Surgery in the Elderly: A Review of the ANZSCTS Database. Heart Lung Circ 2015; 24:1225-32. [DOI: 10.1016/j.hlc.2015.04.162] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/24/2015] [Accepted: 04/04/2015] [Indexed: 11/29/2022]
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Cohn WE, Frazier OH, Mallidi HR, Cooley DA. Surgical Treatment of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Barsoum EA, Azab B, Shah N, Patel N, Shariff MA, Lafferty J, Nabagiez JP, McGinn JT. Long-term mortality in minimally invasive compared with sternotomy coronary artery bypass surgery in the geriatric population (75 years and older patients). Eur J Cardiothorac Surg 2014; 47:862-7. [PMID: 24994756 DOI: 10.1093/ejcts/ezu267] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 05/21/2014] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Ischaemic heart disease is the leading cause of death in the elderly population. Coronary artery bypass graft (CABG) surgery via sternotomy remains the standard of care for patients with multivessel coronary artery disease (CAD). Minimally invasive cardiac surgery (MICS)-CABG via left thoracotomy has been used as an alternative to sternotomy. The aim of our study was to assess the overall survival after MICS-CABG and sternotomy-CABG in elderly patients with CAD. METHODS This observational study included patients who underwent coronary bypass from 2005 to 2008. Patients 75 years and older (n = 159) were included in the final analysis. Each arm was further divided into the MICS-CABG group or sternotomy-CABG group. Primary outcome and overall survival were obtained from our records and the social security death index. RESULTS Among patients 75 years and older (159 patients), MICS-CABG had a significantly lower 5-year all-cause mortality than sternotomy-CABG (19.7 vs 47.7%, P < 0.001). Similarly, Kaplan-Meier curves showed significantly higher overall survival in the MICS-CABG group compared with sternotomy-CABG (log-rank P = 0.014). After adjusting for confounders, MICS-CABG demonstrated a lower mortality than sternotomy-CABG (HR 0.51, 95% confidence interval 0.26-0.97, P = 0.04). For patients less than 75 years old, MICS and sternotomy groups had similar survival according to both uni- and multivariate analyses. CONCLUSIONS The adjusted models demonstrated that MICS-CABG has a significantly better long-term survival than sternotomy-CABG despite slightly differing baseline characteristics. Further studies are needed to compare the short- and long-term outcomes of the two approaches among the elderly population.
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Affiliation(s)
- Emad A Barsoum
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Basem Azab
- Department of Surgery, Staten Island University Hospital, Staten Island, NY, USA
| | - Neeraj Shah
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Nileshkumar Patel
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Masood A Shariff
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY, USA
| | - James Lafferty
- Department of Cardiology, Staten Island University Hospital, Staten Island, NY, USA
| | - John P Nabagiez
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY, USA
| | - Joseph T McGinn
- Department of Surgery, Staten Island University Hospital, Staten Island, NY, USA Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY, USA
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Tsakiridis K, Mpakas A, Kesisis G, Arikas S, Argyriou M, Siminelakis S, Zarogoulidis P, Katsikogiannis N, Kougioumtzi I, Tsiouda T, Sarika E, Katamoutou I, Zarogoulidis K. Lung inflammatory response syndrome after cardiac-operations and treatment of lornoxicam. J Thorac Dis 2014; 6 Suppl 1:S78-98. [PMID: 24672703 DOI: 10.3978/j.issn.2072-1439.2013.12.07] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 12/04/2013] [Indexed: 12/19/2022]
Abstract
The majority of patients survive after extracorporeal circulation without any clinically apparent deleterious effects. However, disturbances exist in various degrees sometimes, which indicate the harmful effects of cardiopulmonary bypass (CPB) in the body. Several factors during extracorporeal circulation either mechanical dependent (exposure of blood to non-biological area) or mechanical independent (surgical wounds, ischemia and reperfusion, alteration in body temperature, release of endotoxins) have been shown to trigger the inflammatory reaction of the body. The complement activation, the release of cytokines, the leukocyte activation and accumulation as well as the production of several "mediators" such as oxygen free radicals, metabolites of arachidonic acid, platelet activating factors (PAF), nitric acid, and endothelin. The investigation continues today on the three metabolites of lornoxicam (the hydroxylated metabolite and two other metabolites of unknown chemical composition) to search for potential new pharmacological properties and activities.
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Affiliation(s)
- Kosmas Tsakiridis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Andreas Mpakas
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - George Kesisis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Stamatis Arikas
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Michael Argyriou
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Stavros Siminelakis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Paul Zarogoulidis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Nikolaos Katsikogiannis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Ioanna Kougioumtzi
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Theodora Tsiouda
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Eirini Sarika
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Ioanna Katamoutou
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Konstantinos Zarogoulidis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
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Khan MS, Islam MYU, Ahmed MU, Bawany FI, Khan A, Arshad MH. On pump coronary artery bypass graft surgery versus off pump coronary artery bypass graft surgery: a review. Glob J Health Sci 2014; 6:186-93. [PMID: 24762361 PMCID: PMC4825227 DOI: 10.5539/gjhs.v6n3p186] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 01/27/2014] [Accepted: 01/23/2014] [Indexed: 12/16/2022] Open
Abstract
There are two basic ways of performing coronary artery bypass graft surgery (CABG): on pump CABG and off pump CABG. Off pump CABG is relatively a newer procedure to on-pump CABG and does not require the use of the cardiopulmonary bypass machine. On pump CABG is the more traditional method of performing bypass surgery. However its resultant inflammatory effects cause renal dysfunction, gastrointestinal distress and cardiac abnormalities which have forced the surgeons to look for alternatives to the procedure. An extensive literature search revealed that on pump CABG causes better revascularization as compared to off pump CABG while off pump CABG has a much lower post operative morbidity and mortality especially in high risk patients. We suggest that the technique used should depend on the ease of the surgeon doing the operation as both the methods seem almost equally efficient according to the review.
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Abstract
Coronary artery disease is one of the leading causes of illness for both men and women. However, women are 3 times more likely to die for coronary artery disease as they are of breast cancer. There are an increasing prevalence of coronary artery disease in women and thus facing the need for surgical revascularization. It has long being accepted that women carry a high risk of coronary surgery than men. Many investigators have suggested that female itself is predictive of poor outcome after on pump coronary surgery. We thought to search the litlature to investigate whether women who undergo off-pump surgery receive any benefits compared with women undergoing on-pump surgery.
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Raja SG. Myocardial revascularization for the elderly: current options, role of off-pump coronary artery bypass grafting and outcomes. Curr Cardiol Rev 2013; 8:26-36. [PMID: 22845813 PMCID: PMC3394105 DOI: 10.2174/157340312801215809] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Revised: 03/19/2012] [Accepted: 03/23/2012] [Indexed: 12/22/2022] Open
Abstract
The increase in life expectancy has confronted cardiac surgery with a rapidly growing population of elderly patients requiring surgical myocardial revascularization. Recent advances in surgical and anesthetic techniques and improvements in postoperative care have made coronary artery bypass grafting an established therapeutic option for the treatment of coronary artery disease in this group of patients. However, conventional coronary artery bypass grafting on cardiopulmonary bypass is associated with significant risk and related morbidity and mortality in the elderly. In recent years off-pump coronary artery bypass grafting has emerged as a safe and less invasive strategy for surgical myocardial revascularization. Off-pump coronary artery bypass grafting by avoiding the deleterious effects of cardiopulmonary bypass can offer potential benefits to elderly patients requiring surgical myocardial revascularization. This review article provides an overview of the age-related cardiovascular changes, epidemiology of coronary artery disease in the elderly and focuses on outcomes of surgical myocardial revascularization with special emphasis on the impact of off-pump coro-nary artery bypass surgery in the elderly.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, United Kingdom.
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Girerd N, Magne J, Rabilloud M, Charbonneau E, Mohamadi S, Pibarot P, Voisine P, Baillot R, Doyle D, Dumont E, Dagenais F, Mathieu P. The Impact of Complete Revascularization on Long-Term Survival Is Strongly Dependent on Age. Ann Thorac Surg 2012; 94:1166-72. [DOI: 10.1016/j.athoracsur.2012.05.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 04/30/2012] [Accepted: 05/03/2012] [Indexed: 10/28/2022]
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Houlind K, Kjeldsen BJ, Madsen SN, Rasmussen BS, Holme SJ, Schmidt TA, Haahr PE, Mortensen PE. The impact of avoiding cardiopulmonary by-pass during coronary artery bypass surgery in elderly patients: the Danish On-pump Off-pump Randomisation Study (DOORS). Trials 2009; 10:47. [PMID: 19575814 PMCID: PMC2716313 DOI: 10.1186/1745-6215-10-47] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 07/04/2009] [Indexed: 11/22/2022] Open
Abstract
Background Coronary Artery Bypass Graft operation for ischemic heart disease provides improved quality of life and, in some patients, prolonged survival. Concern has, however, been raised about complications that may be related to the use of cardiopulmonary by-pass (CPB) and aortic cross-clamping. It has been hypothesized that when coronary artery by-pass grafting is performed without the use of CPB, the rate of serious complications is reduced. Methods/Design The trial is designed as an open, randomized, controlled, clinical trial with blinded assessment of end-points. Patients at or above 70 years of age, referred for surgical myocardial revascularisation, are included and randomised to receive coronary artery by-pass grafting either with or without the use of CPB and aortic cross-clamping. Follow-up is performed by clinical, biochemical, electrocardiographic, and angiographic data that are evaluated by independent committees that are blinded with respect to the result of the randomisation. End points include mortality, stroke, myocardial infarction, graft patency, quality of life, and cost-effectiveness. The trial is performed in four different Danish, cardiac surgery centres. Trial registration ClinicalTrials.gov NCT00123981
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Affiliation(s)
- Kim Houlind
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Denmark.
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Kempfert J, Opfermann UT, Richter M, Bossert T, Mohr FW, Gummert JF. Twelve-Month Patency With the PAS-Port Proximal Connector Device: A Single Center Prospective Randomized Trial. Ann Thorac Surg 2008; 85:1579-84. [DOI: 10.1016/j.athoracsur.2008.01.074] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2007] [Revised: 01/18/2008] [Accepted: 01/18/2009] [Indexed: 11/25/2022]
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13
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Wan S, Underwood MJ. Cardiovascular Surgery in the Aging World. Intensive Care Med 2007. [DOI: 10.1007/978-0-387-49518-7_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Affiliation(s)
- Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, 9500 Euclid Ave F24, Cleveland, OH 44195, USA.
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15
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Bolotin G, Shapira Y, Gotler Y, Frolkis IV, Ben-Gal Y, Nesher N, Uretzky G. The potential advantage of “no-touch” aortic technique in off-pump complete arterial revascularization. Int J Cardiol 2007; 114:11-5. [PMID: 16690146 DOI: 10.1016/j.ijcard.2005.11.107] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2005] [Revised: 11/10/2005] [Accepted: 11/17/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Off-pump coronary artery bypass grafting (OPCAB) and complete arterial revascularization without proximal anastomosis to the aorta may decrease neurological events after open-heart surgery. Few reports exist regarding the combination of OPCAB and complete arterial revascularization exploring the theoretical advantage of avoiding manipulation of the aorta. We review our results in 110 patients who underwent multiple grafts off-pump complete arterial revascularization. METHODS 110 patients underwent multiple grafts OPCAB complete arterial revascularization, and were compared to 216 patients who underwent traditional multiple grafts on pump CABG. Preoperative renal failure was 12.7% (n=14) as compared to 5.1%, (n=11, p=0.01) in the control group and 33.6% (n=37) of the patients were 75 years or older as compared to 19.0% (n=41, p=0.003) in the control group. RESULTS The mean number of grafts per patient undergoing multiple OPCAB complete arterial revascularization was 2.3, as compared to 3.11 in the control group (p<0.001). The mortality rate was 2.73% as compared to 1.85% (NS) in the control group. The incidence of CVA was 0% as compared to 2.31% (p=0.17) in the control group. CONCLUSIONS Complete arterial OPCAB revascularization without manipulation of the aorta in high-risk patients can be performed with short-term similar results to conventional CABG and very low neurological complications.
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Affiliation(s)
- Gil Bolotin
- The Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel-Aviv, 64239, Israel.
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Surgical Treatment of Coronary Artery Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Koronarchirurgische Intervention bei Patienten in der achten Lebensdekade. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2006. [DOI: 10.1007/s00398-006-0553-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nagpal AD, Bhatnagar G, Cutrara CA, Ahmed SM, McKenzie N, Quantz M, Kiaii B, Menkis A, Fox S, Stitt L, Novick RJ. Early outcomes of coronary artery bypass with and without cardiopulmonary bypass in octogenarians. Can J Cardiol 2006; 22:849-53. [PMID: 16957802 PMCID: PMC2569020 DOI: 10.1016/s0828-282x(06)70303-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Off-pump coronary artery bypass (OPCAB) surgery has been successfully used in diverse patient populations and has been postulated to be safer than conventional coronary artery bypass (CCAB) surgery in some high-risk patients, including the elderly. OBJECTIVE To compare the safety of OPCAB surgery versus CCAB surgery in the octogenarian population of two large southwestern Ontario cardiac surgical units. RESULTS Two hundred thirty-six consecutive octogenarians underwent primary isolated coronary artery bypass surgery from November 2000 to March 2005. Patients undergoing OPCAB surgery tended to have higher Parsonnet scores, while patients undergoing CCAB surgery had a greater number of emergent operations. The Canadian Cardiovascular Network predicted that mortality risk was similar in both groups. In-hospital mortality was similar between groups, as was postoperative myocardial infarction and new onset of renal dysfunction. However, in the OPCAB group, there was a decreased incidence of postoperative neurological dysfunction (2.3% in the OPCAB group versus 10.5% in the CCAB group, P=0.01), in particular cerebrovascular accidents (1.5% in the OPCAB group versus 7.6% in the CCAB group, P=0.05), and a decreased incidence of prolonged intubation (5.3% in the OPCAB group versus 13.3% in the CCAB group, P=0.04). Multivariable analysis found that cardiopulmonary bypass had no significant impact on mortality or length of stay. CONCLUSIONS In octogenarian patients, OPCAB surgery is as safe as CCAB surgery in terms of mortality and major morbidity. Furthermore, a significant reduction in neurological dysfunction and prolonged intubation was seen in the OPCAB group compared with the CCAB group.
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Affiliation(s)
- A D Nagpal
- Division of Cardiac Surgery, London Health Sciences Centre, London, Ontario.
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Panesar SS, Athanasiou T, Nair S, Rao C, Jones C, Nicolaou M, Darzi A. Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing coronary artery bypass grafting--comparison between off-pump and on-pump techniques. Heart 2006; 92:1808-16. [PMID: 16775087 PMCID: PMC1861313 DOI: 10.1136/hrt.2006.088450] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To assess early outcomes in the elderly population undergoing coronary revascularisation with and without cardiopulmonary bypass (CPB). METHODS Meta-analysis of all retrospective, non-randomised studies comparing off-pump coronary artery bypass (OPCAB) versus CPB techniques in the elderly (> 70 years) between 1999 and 2005. Age-related early outcomes of interest were death, stroke, atrial fibrillation (AF), renal failure and length of stay in hospital. The random effects model was used. Sensitivity and heterogeneity were analysed. RESULTS Analysis of 14 non-randomised studies comprising 4921 patients (OPCAB, 1533 (31.1%) and CPB, 3388 (68.9%)) showed a significantly lower incidence of death in the OPCAB group (odds ratio (OR) 0.48, 95% CI 0.28 to 0.84). This effect was greater in OPCAB octogenarians (OR 0.26, 95% CI 0.12 to 0.57). The pattern of incidence of stroke among the OPCAB octogenarians (OR 0.19, 95% CI 0.07 to 0.56) was similar. The incidence of AF was lower in the OPCAB group (OR 0.77, 95% CI 0.61 to 0.97). The incidence of renal failure did not differ. Length of hospital stay was shorter in the OPCAB group, although with significant heterogeneity. CONCLUSIONS OPCAB may be associated with lower incidence of death, stroke and AF in the elderly, which may result in shorter length of hospital stay. A large randomised trial would confirm whether the elderly would benefit more from OPCAB surgery.
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Affiliation(s)
- S S Panesar
- Department of Surgical Oncology & Technology, Imperial College, London, UK
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Clark JA, Bar-Yosef S, Anderson A, Newman MF, Landolfo K, Grocott HP. Postoperative Hyperthermia Following Off-Pump Versus On-Pump Coronary Artery Bypass Surgery. J Cardiothorac Vasc Anesth 2005; 19:426-9. [PMID: 16085244 DOI: 10.1053/j.jvca.2005.01.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Hyperthermia is common in the first 24 hours following coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CPB). An inflammatory response to CPB is often implicated in the pathophysiology of this fever. Unlike CABG with CPB, the temperature pattern after off-pump CABG (OPCAB), where CPB is avoided, has not yet been described. The purpose of this study was to describe the postoperative temperature pattern following OPCAB and to compare it with that following on-pump cardiac surgery. DESIGN Retrospective, observational study. SETTING Tertiary care university hospital. PARTICIPANTS Consenting patients undergoing CABG or OPCAB procedures. INTERVENTIONS Observational. MEASUREMENTS AND MAIN RESULTS Of the CABG patients, 89% had temperature elevations above 38 degrees C, versus 44% of the OPCAB patients (P = 0.04). Peak body temperature was higher in the on-pump patients (CABG 38.5 degrees C +/- 0.4 degrees C versus OPCAB 37.9 degrees C +/- 0.5 degrees C; P = 0.002), as was the area under the curve for temperatures greater than 38 degrees C (CABG 1.6 +/- 1.7 degrees C/hr versus OPCAB 0.4 +/- 1.2 degrees C/hr; P = 0.02). CONCLUSIONS Off-pump CABG surgery patients experience less hyperthermia compared with on-pump CABG patients. The reasons for a lower incidence and severity of hyperthermia after OPCAB surgery are not known, but may be related to a reduced inflammatory response.
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Affiliation(s)
- Jeffrey A Clark
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Matsuura K, Kobayashi J, Tagusari O, Bando K, Niwaya K, Nakajima H, Yagihara T, Kitamura S. Off-Pump Coronary Artery Bypass Grafting Using Only Arterial Grafts in Elderly Patients. Ann Thorac Surg 2005; 80:144-8. [PMID: 15975357 DOI: 10.1016/j.athoracsur.2005.01.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2004] [Revised: 01/10/2005] [Accepted: 01/17/2005] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study aimed to elucidate the safety and feasibility of off-pump coronary artery bypass grafting with only arterial grafts for elderly patients. METHODS Of 653 patients who underwent off-pump coronary artery bypass grafting from April 2000 to December 2003, 581 patients did so with only arterial grafts. The average age was 66.9 +/- 9.3 years. The patients were divided into the elder group E (75 years old or more: 111 cases) or the younger group Y (younger than 75 years old: 470 cases). The mean follow-up term was 21 +/- 12 months. RESULTS Additive and logistic EuroSCOREs of group E were significantly higher than those of group Y (p < 0.0001). The number of bypass grafts was 3.3 +/- 0.9 in group E and 3.3 +/- 1.1 in group Y (p = 0.43). The proportion of total revascularization was 74% (82 of 111) in group E and 80% (377 of 470) in group Y (p = 0.15). The number of bilateral implementations of internal thoracic artery was 10 (9.0%) in group E and 196 (42%) in group Y (p < 0.0001). The graft patency rate was 98.7% in group E and 97.8% in group Y (p = 0.96). Hospital mortality was 2.7% (3 of 111) in group E and 0.2% (1 of 470) in group Y (p = 0.095). The causes of death were unrelated to cardiac events. Major adverse cardiac events occurred in 5 patients (5.1%) in group E and in 24 patients (5.6%) in group Y (p > 0.99). CONCLUSIONS Off-pump coronary artery bypass grafting using only arterial grafts in elderly patients is as safe and feasible as in young patients.
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Affiliation(s)
- Kaoru Matsuura
- Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
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Yap A, Baladi N, Zapolanski A, Pliam MB, Shaw RE. Influence of body size on outcomes of off-pump coronary artery bypass surgery. Heart Surg Forum 2005; 8:E190-5. [PMID: 15937004 DOI: 10.1532/hsf98.20051004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Patients of small physical stature may be more likely selected for an on-pump coronary artery surgery (ONCAB) rather than an off-pump procedure (OPCAB). Small patients who do have OPCAB may do poorly. Our hospital demographics afford a unique opportunity to examine a group of small patients. METHODS Information was available over the past 4 years on 1015 patients who had isolated CABG and a calculable body surface area. Sixty-one patients had a body surface area of less than 1.5 m2 (SMALL). The 954 remaining patients were classed as larger (LARGER). Patients were compared with respect to preoperative risk factors, operative procedures, and postoperative results. RESULTS Among SMALL patients, 59% were Asian, 89% female, averaged slightly older, had higher STS risk scores, lower hematocrits, more severe NYHA class ratings, and less elective surgical status (P < .05) than LARGER patients. Fifty-one percent of SMALL patients had OPCAB, 44.3% received blood, 90% had an event-free course, and 4.9% died postop (versus 1.2%, P < .05). OPCAB mortality was lower than ONCAB for both SMALL and nonsmall (P < .05). Blood use was greater for SMALL than for LARGER (44% versus 20%, P < .05) but less for SMALL OPCAB than SMALL ONCAB (27% versus 62%, P < .05). No differences were noted in postop MI, CVA, or length of stay, but 30-day readmission was lower for SMALL patients (5.0% versus 7.4%). CONCLUSIONS Patients with small physical stature can be safely operated upon using off-pump techniques with good revascularization and postop results, despite apparently higher preop STS risk scores.
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Affiliation(s)
- Alexander Yap
- Department of Cardiovascular Surgery, Seton Medical Center, San Francisco Heart & Vascular Institute, Daly City, California, USA.
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23
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Sellke FW, DiMaio JM, Caplan LR, Ferguson TB, Gardner TJ, Hiratzka LF, Isselbacher EM, Lytle BW, Mack MJ, Murkin JM, Robbins RC. Comparing On-Pump and Off-Pump Coronary Artery Bypass Grafting. Circulation 2005; 111:2858-64. [PMID: 15927994 DOI: 10.1161/circulationaha.105.165030] [Citation(s) in RCA: 195] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
One of the most hotly debated and polarizing issues in cardiac surgery has been whether coronary artery bypass grafting (CABG) without the use of cardiopulmonary bypass or cardioplegia (off-pump CABG, or OPCAB) is superior to that performed with the heart-lung machine and the heart’s being chemically arrested (standard CABG). Various clinical trials are reviewed comparing the 2 surgical strategies, including several large retrospective analyses, meta-analyses, and the randomized trials that address different aspects of standard CABG and OPCAB. Although definitive conclusions about the relative merits of standard CABG and OPCAB are difficult to reach from these varied randomized and nonrandomized studies, several generalizations may be possible. Patients may achieve an excellent outcome with either type of procedure, and individuals’ outcomes likely depend more on factors other than whether they underwent standard CABG or OPCAB. Nevertheless, there appear to be trends in most studies. These trends include less blood loss and need for transfusion after OPCAB, less myocardial enzyme release after OPCAB up to 24 hours, less early neurocognitive dysfunction after OPCAB, and less renal insufficiency after OPCAB. Fewer grafts tend to be performed with OPCAB than with standard CABG. Length of hospital stay, mortality rate, and long-term neurological function and cardiac outcome appear to be similar in the 2 groups. To definitively answer the remaining questions of whether either strategy is superior and in which patients, a large-scale prospective randomized trial is required.
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Lee JW, Ryu SW, Song H, Kim KS, Yang YJ, Moon DH. Evaluation of Myocardial Flow Reserve Using Pharmacological Stress Thallium-201 Single-Photon Emission Computed Tomography: Is There a Difference between Total Arterial Off-Pump Coronary Artery Bypass Grafting and Conventional Coronary Artery Bypass. Heart Surg Forum 2004; 7:E471-6. [PMID: 15799928 DOI: 10.1532/hsf98.20041071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The advantage of total arterial off-pump coronary bypass grafting (OPCAB) over conventional onpump coronary artery bypass grafting with 1 internal thoracic artery and veins (CCAB) in terms of myocardial flow reserve has not been studied. We studied these procedures using thallium- 201 perfusion single-photon emission computed tomography (Tl-201 perfusion SPECT). METHODS Between 1997 and 2001, 152 patients were recruited from our database (OPCAB, n = 100; CCAB, n = 52). All patients underwent pharmacological stress Tl-201 perfusion SPECT 3 to 12 months after bypass surgery. Myocardial perfusion was analyzed semiquantitatively with a 5-point scoring system in a 20-segment model (0, normal, to 4, absence of uptake). Summed stress (SSS), rest (SRS), and difference score (SDS) of the entire myocardium as well as average scores (ASS, ARS, ADS) of individual walls (anterior, septal, lateral, and inferior) were compared by Student t test as well as by repeated-measures analysis of variance with Bonferroni correction. RESULTS The SSS, SRS, and SDS of OPCAB versus those of CCAB were 6.86 +/- 0.72 versus 7.17 +/- 0.92, 3.95 +/- 0.57 versus 3.75 +/- 0.73, and 2.91 +/- 0.47 versus 3.42 +/- 0.74 (P > .05). However, the lateral wall showed lower scores in OPCAB (ASS, 0.18 versus 0.41, P = .015; ARS, 0.12 versus 0.20, P = .168; ADS, 0.06 versus 0.21, P = .031). The septal wall had higher scores in OPCAB (ASS, 0.33 versus 0.12, P = .003; ARS, 0.18 versus 0.07, P = .037; ADS, 0.14 versus 0.04, P = .030). The anterior and inferior walls were not different between the 2 groups. CONCLUSIONS OPCAB led to results similar to those of CCAB. The better results in the lateral wall have been the effect of grafting radial artery rather than vein. The similarity in myocardial reserve in the inferior wall between the 2 groups needs further study. There was no deleterious effect of off-pump as opposed to on-pump CAB.
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Affiliation(s)
- Jae Won Lee
- Department of Thoracic, Asan Medical Center, Seoul, Korea.
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Peterson ED, Alexander KP, Malenka DJ, Hannan EL, O'Conner GT, McCallister BD, Weintraub WS, Grover FL. Multicenter experience in revascularization of very elderly patients. Am Heart J 2004; 148:486-92. [PMID: 15389237 DOI: 10.1016/j.ahj.2004.03.039] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Very elderly patients are increasingly referred for revascularization yet have been underrepresented in both prior percutaneous coronary intervention (PCI) and coronary bypass surgery (CABG) clinical trials. We pooled the largest PCI and CABG clinical registries in the United States to better understand revascularization procedure use, risks and outcomes in patients aged > or =75 years. METHODS Six PCI registries (n = 48,439) and 8 CABG registries (n = 180,709) voluntarily contributed all procedural data in patients aged > or =75 years from 1990 through 1999. Patient characteristics, procedural process, and inhospital mortality and morbidity outcomes were evaluated. Risk factors for mortality in elderly patients were identified and compared across registries using standardized multivariable logistic regression. RESULTS Between the years 1991 and 1999, the proportion of patients aged > or =75 years undergoing revascularization was on the rise (10% increase). Pooled estimates of inhospital mortality following PCI during this decade was 3.0% (range 1.5%-5.2% among databases), and following CABG was 5.9% (range 4.9%-8.4% among databases). Mortality rates declined significantly in older patients for both PCI and CABG over this decade. While process measures varied across registries, the most significant predictors of inhospital death (procedural urgency, left ventricular dysfunction, prior CABG) seemed consistent across all sites. CONCLUSION Over the last decade, the use of coronary revascularization in elderly patients increased and outcomes improved. While age remains a determinant of procedural risk, this risk varies markedly among elderly patients, emphasizing the need for individualized risk assessments.
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Affiliation(s)
- Eric D Peterson
- The Outcomes Research and Assessment Group, The Duke Clinical Research Institute, Durham, NC 27715, USA.
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26
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Athanasiou T, Aziz O, Mangoush O, Weerasinghe A, Al-Ruzzeh S, Purkayastha S, Pepper J, Amrani M, Glenville B, Casula R. Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann Thorac Surg 2004; 77:1567-74. [PMID: 15111144 DOI: 10.1016/j.athoracsur.2003.10.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Atrial fibrillation is the most common postoperative complication in patients undergoing coronary artery bypass grafting (CABG) with advancing age having been shown to have a significant association with its incidence. This study aims to assess whether off-pump coronary artery bypass (OPCAB) reduces the incidence of atrial fibrillation in elderly patients. METHODS A meta-analysis of all observational studies reporting a comparison between the two techniques in elderly patients (> 70 years) between 1999-2003 was performed. The primary outcome of interest was the incidence of postoperative atrial fibrillation. The quality of each study was evaluated by examining three items: patient selection, matching of the off-pump and cardiopulmonary bypass patient groups, and assessment of outcome. Meta-regression analysis was undertaken to see the effects of study size and quality on the calculated odds ratio. RESULTS Eight studies fulfilled our inclusion criteria, all of which were nonrandomized. In total the studies identified 3017 subjects, of which 764 had off-pump surgery (25%) and 2253 underwent cardiopulmonary bypass (75%). Meta-analysis showed that after off-pump surgery there was a significantly lower incidence of postoperative atrial fibrillation in these patients (odds ratio 0.70, 95% confidence interval [CI] 0.56-0.89). Meta-regression analysis including study characteristics did not show any associations affecting the calculated odds ratio of atrial fibrillation. CONCLUSIONS Our study demonstrates a reduced incidence of postoperative atrial fibrillation in an elderly population with off-pump as compared with cardiopulmonary bypass techniques. We appreciate, however, that our statistical analysis uses nonrandomized published data and that the results must be treated with caution. If this finding is confirmed by a large-scale randomized trial, it has significant implications on the operative strategy employed for this patient group.
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Affiliation(s)
- Thanos Athanasiou
- The National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, Department of Cardiothoracic Surgery, St. Mary's Hospital and Royal Brompton Hospital, London, United Kingdom.
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27
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Athanasiou T, Al-Ruzzeh S, Kumar P, Crossman MC, Amrani M, Pepper JR, Del Stanbridge R, Casula R, Glenville B. Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients. Ann Thorac Surg 2004; 77:745-53. [PMID: 14759484 DOI: 10.1016/j.athoracsur.2003.07.002] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Several recent studies have highlighted the potential benefits of using off-pump coronary artery bypass (OPCAB) surgery, particularly in high-risk patients. The aim of this meta-analysis is to assess the effect of OPCAB on the incidence of stroke compared with coronary artery bypass grafting using cardiopulmonary bypass (CPB) in elderly patients. We performed a meta-analysis of all observational studies, published in MEDLINE between 1999 and 2002 and a comparison between the OPCAB and CPB techniques in elderly patients was performed with the outcome of interest being the incidence of stroke. Elderly patients were defined as those aged 70 years or older. Nine studies are included in the meta-analysis. The total number of subjects included was 4,475 patients, of which, 1,253 underwent OPCAB (28%) and 3,222 (72%) underwent CPB. The meta-analysis showed that the OPCAB technique was associated with significantly lower incidence of stroke in elderly patients compared with the CPB technique (1% vs 3%), with an odds ratio of 0.38% to 95% (CI, 0.22 to 0.65). We did not identify any significant heterogeneity and funnel plot asymmetry between the studies included in the meta-analysis. Meta-regression analysis including variables predicting stroke, mortality, and study characteristics did not show any associations affecting the calculated odds ratio of stroke. Despite the fact that this is a meta-analysis of observational studies and adjustment for differences in baseline risk factors between OPCAB and CPB patients was not possible, we believe that this study suggests that the OPCAB technique might be associated with reduced incidence of stroke in the elderly patients undergoing coronary artery bypass grafting.
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Affiliation(s)
- Thanos Athanasiou
- Department of Cardiothoracic Surgery, The National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, United Kingdom.
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Affiliation(s)
- Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, F-25, Cleveland, Ohio 44195, USA.
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Boening A, Friedrich C, Hedderich J, Schoettler J, Fraund S, Cremer JT. Early and medium-term results after on-pump and off-pump coronary artery surgery: a propensity score analysis. Ann Thorac Surg 2003; 76:2000-6. [PMID: 14667630 DOI: 10.1016/s0003-4975(03)01298-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Comparative publications on beating-heart off-pump coronary artery bypass grafting (OPCAB) surgery versus conventional coronary artery bypass grafting (CCAB) surgery frequently do not offer conclusive information because of investigator bias. METHODS Trying to eliminate this problem, a propensity score analysis of the data of all CCAB patients (n = 517) and OPCAB patients (n = 133) operated on by the same surgeons during the same time period (1998 to 2001) was applied. After matching patients with similar propensity score values, 97 CCAB patients and 72 OPCAB patients entered the final analysis. RESULTS Early results were similar in both groups: the 30-day mortality reached 1.4% in the CCAB group and 2.8% in the OPCAB group; strokes did not happen. Perioperative myocardial infarctions occurred in 4.1% of the CCAB patients and 4.3% of the OPCAB patients. Drainage blood loss in the first 24 hours after surgery (830 +/- 687 mL, CCAB group; and 909 +/- 678 mL, OPCAB group) was similar (p = 0.06) in both groups. Medium term results (freedom from percutaneous transluminal coronary angioplasty or reoperation, freedom from myocardial infarction, freedom from stroke, and the quality of life) also were not significantly different between the off-pump and on-pump groups after a mean follow-up of 27 +/- 11 months. CONCLUSIONS Our results suggest that elective-surgery patients with coronary artery disease can be operated on either on-pump or off-pump with the same early and late mortality and morbidity.
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Affiliation(s)
- Andreas Boening
- Department of Cardiovascular Surgery, University Hospital, Kiel, Germany.
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30
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Affiliation(s)
- Robert A Lancey
- Bassett Heart Care Institute, Mary Imogene Bassett Hospital, Cooperstown, New York, USA
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Lin CY, Hong GJ, Lee KC, Loh SH, Tsai CS. Off-pump technique in coronary artery bypass grafting in elderly patients. ANZ J Surg 2003; 73:473-6. [PMID: 12864818 DOI: 10.1046/j.1445-1433.2003.02667.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The use of cardiopulmonary bypass (CPB) during coronary artery bypass grafting (CABG) is associated with substantial morbidity and mortality, especially in the elderly. The purpose of this study was to evaluate the feasibility of beating heart coronary artery revascularization in patients aged at least 80 years. METHODS A retrospective chart review was carried out for 17 patients aged over 80 years who underwent isolated off-pump CABG at the Tri-Service General Hospital, Taiwan, during the period July 1999 to December 2000. The demographic characteristics, operative data, postoperative results and short-term outcomes of patients were compared with those of 12 patients who underwent conventional CABG using CPB during the same time period. RESULTS The off-pump group consisted of 13 men and four women with a mean age of 82.2 +/- 0.9 years and an ejection fraction of 53.4 +/- 4.1%. The on-pump group consisted of eight men and four women with a mean age of 83.5 +/- 0.5 and an ejection fraction of 42.0 +/- 4.8%. The mean number of anastomoses performed per patient was 3.1 +/- 0.3 in the off-pump group and 3.0 +/- 0.14 in the on-pump group. There was no occurrence of stroke, myocardial infarction, re-entry for bleeding or renal failure among patients in the off-pump group. Intubation time (10.6 vs 48.4 h), intensive care unit stay (2.9 vs 4.2 days) and postoperative stay (12.7 vs 18.1 days) were significantly shorter in the off-pump group than in the on-pump group. No patient died in the off-pump group, whereas one patient died in the on-pump group. CONCLUSIONS The results of this study suggest that the off-pump technique is a safe and efficacious method for myocardial revascularization in elderly patients and that the short-term outcome obtained with this technique are promising. Our data suggest that the off-pump technique is preferable in these patients.
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Affiliation(s)
- Chih-Yuan Lin
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Abstract
The number of aged individuals is growing, and consequently the demands on resources for cardiac surgery will increase in the elderly. Even in the absence of obvious coexisting diseases, advanced age is always accompanied by a general decline in organ functions, and specifically by changes in structure and function of the heart and vasculature that will ultimately affect cardiovascular performance (e.g. hypertension, ischaemic heart disease, etc.). These alterations have to be taken into account when older patients require anaesthesia for cardiac surgery. Pre-operative examination must be performed carefully to estimate cardiac function as well as dysfunction of other organ systems. Benzodiazepines as well as alpha2-adrenoceptor agonists can be used for pre-medication; induction and maintenance of anaesthesia can be performed as balanced anaesthesia or total intravenous anaesthesia. Essential monitoring should include pulmonary artery catheterization and/or transoesophageal echocardiography. During cardiac surgery the risk for elderly individuals is increased; in particular, the central nervous system is more often compromised in the elderly than in younger patients. However, elderly patients without significant co-morbidity have a mortality rate comparable to that of younger patients.
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Affiliation(s)
- F Wappler
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, Martinistrasse 52, Hamburg D-20246, Germany.
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Abstract
During the past decade, technical improvements have made off-pump coronary artery bypass operations a routine procedure. During this time, off-pump coronary artery bypass has been audited against conventional techniques by many observational, case-matched, and prospective randomized studies. There is evidence in the literature suggesting that off-pump coronary artery bypass operations reduce postoperative morbidity, organ dysfunction, and costs, without compromising midterm outcome compared with conventional coronary operations. The available evidence also supports the view that high-risk patients might benefit the most from revascularization on the beating heart. High quality follow-up data are still needed to assess the impact of off-pump coronary artery bypass operations on long-term clinical outcome.
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Affiliation(s)
- Raimondo Ascione
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
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Scarborough JE, White W, Derilus FE, Mathew JP, Newman MF, Landolfo KP. Neurologic outcomes after coronary artery bypass grafting with and without cardiopulmonary bypass. Semin Thorac Cardiovasc Surg 2003; 15:52-62. [PMID: 12813690 DOI: 10.1016/s1043-0679(03)70042-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neurologic injury, in the form of either stroke or more subtle neurocognitive impairment, is a frequent and potentially devastating complication of coronary artery bypass grafting (CABG). The etiology of CABG-associated neurologic injury is likely multifactorial, with the phenomena of cerebral hypoperfusion and embolism being the major contributors. Several perioperative strategies have been developed in an effort to reduce the incidence of CABG-associated neurologic complications. Hypothermic cerebral perfusion, alpha stat acid-base management, and slow patient rewarming have been shown by several investigators to minimize adverse neurologic sequelae associated with the use of cardiopulmonary bypass. Performing CABG without cardiopulmonary bypass (off-pump CABG), meanwhile, has been shown to reduce the risk of perioperative stroke, especially in high-risk patients such as the elderly. Whether off-pump CABG reduces the incidence of less severe neurocognitive impairment has not yet been clearly established and merits further investigation in the form of large, multicenter, randomized trials. Other technical innovations, such as the use of sutureless and clampless aortic anastomotic devices, also may be able to further minimize the neurologic complications associated with CABG.
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Affiliation(s)
- John E Scarborough
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Hoff SJ, Ball SK, Coltharp WH, Glassford DM, Lea JW, Petracek MR. Coronary artery bypass in patients 80 years and over: is off-pump the operation of choice? Ann Thorac Surg 2002; 74:S1340-3. [PMID: 12400813 DOI: 10.1016/s0003-4975(02)03913-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Octogenarians are at increased risk for perioperative morbidity and mortality after coronary artery bypass. In this study we compared our experience with patients undergoing on-pump coronary artery bypass (CAB) and those undergoing off-pump coronary artery bypass (OPCAB) to assess outcomes. METHODS We used hospital database analysis in patients 80 years and older who underwent nonemergent coronary artery bypass with (N = 169) and without (N = 60) cardiopulmonary bypass from January 1999 through June 2001. RESULTS Both groups were at increased perioperative risk based on the Society of Thoracic Surgeons risk model (7.7% OPCAB vs 5.8% CAB, p = 0.03). There were no operative deaths in the OPCAB group but there were eight (4.7%) in the CAB group (p = NS). Perioperative stroke (0% OPCAB vs 7.1% CAB, p = 0.04), prolonged ventilation (1.7% OPCAB vs 11.8% CAB, p = 0.02), and transfusion rate (33% OPCAB vs 70.4% CAB, p < 0.001) were all lower in the OPCAB group. A shorter hospital stay (6.3 days OPCAB vs 11.5 days CAB, p < 0.001) resulted in lower hospital cost in the OPCAB group ($9,363 OPCAB vs $12,312 CAB, p < 0.001). CONCLUSIONS In this study, off-pump coronary artery bypass grafting in elderly patients was associated with fewer complications, a shorter hospital stay, and lower hospital cost. Off-pump coronary artery bypass grafting may be the operation of choice for octogenarians requiring surgical myocardial revascularization.
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Affiliation(s)
- Steven J Hoff
- St. Thomas Heart Institute, St. Thomas Hospital, Nashville, Tennessee, USA.
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Hirose H, Amano A, Takahashi A, Takanashi S. Urgent off-pump coronary artery bypass grafting. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2002; 50:330-7. [PMID: 12229216 DOI: 10.1007/bf03032626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The use of off-pump coronary artery bypass grafting (CABG) has become widespread, since it has proven less invasive and to promote early recovery. In this study, we investigated the efficacy of off-pump CABG in patients in the evolving phase of acute myocardial infarction. METHODS Retrospective chart review was carried out for patients undergoing urgent isolated off-pump and on-pump CABG at Shin-Tokyo Hospital Group between January 1991 and June 2001. The patients' demographic, operative data, and postoperative results were collected. RESULTS The off-pump group consisted of 19 males and 11 females with a mean age of 72.0 years and the on-pump group of 91 males and 38 females with a mean age of 64.3 years. Preoperative use of intraaortic balloon pumping and preoperative shock was more frequently observed in the on-pump group. The mean number of distal anastomoses was 3.1 +/- 0.9 in the off-pump group and 3.2 +/- 1.1 in the on-pump group (p = NS). Intubation time (18.5 vs 32.9 hours), ICU stay (3.4 vs 4.9 days), and postoperative stay (13.5 vs 24.3 days) were significantly shorter in the off-pump group than in the on-pump group (P < 0.05). The frequency of the major complications was significantly lower in the off-pump group (9/30, 30%) than the on-pump group (65/129, 50.4%), especially for postoperative low output syndrome (p < 0.05). Multivariate analysis demonstrated a significant reduction in the recovery period by use of off-pump CABG. Early follow-up results were similar between the two groups, in terms of late cardiac events and survival. CONCLUSION Urgent off-pump CABG is safe and provides early recovery, provided that the patient's intraoperative hemodynamics are taken into account.
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Affiliation(s)
- Hitoshi Hirose
- Department of Cardiovascular Surgery, Kobari General Hospital, 29-1 Yokouchi, Noda City, Chiba 278-8501, Japan
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